Angular Deformities Range of Normal Varies With Age During first year : Lateral bowing of Tibiae During second year : Bow legs (knees & tibiae) Between 3 – 4 years : Knock knees
Angular Deformities Evaluation Should differentiate between “physiologic” and “pathologic” deformities
Angular Deformities Evaluation PhysiologicPathologic Expected for age Generalized Regressive Mild – moderate Symmetrical Not expected for age Localized Progressive Severe Asymmetrical
Angular Deformities Causes PhysiologicPathologic - Use of walker? - Early wt. bearing - Overweight Exaggerated : Normal – for age Idiopathic Injury to Epiphys. Plate Infection / Trauma Metabolic disease Endocrine disturbance Rickets
X-ray when severe or possibly pathologic Standing AP film –long film ( hips to ankles ) with patellae directed forwards Look for diseases : –Rickets / Tibia vara (Blount’s) / Epiphyseal injury.. –Measure angles. Angular Deformities Evaluation Investigations / Radiological
Rotational Deformities Level of affection : Femur Tibia Foot
Rotational Deformities Femur Ante-version = more medial rotation Retro-version = more lateral rotation
Rotational Deformities Normal Development Femur : Ante-version : –30 degrees at birth. –10 degrees at maturity. Tibia : Lateral rotation : –5 degrees at birth. –15 degrees at maturity.
Rotational Deformities Normal Development Both Femur and Tibia laterally rotate with growth in children Medial Tibial torsion and Femoral ante-version improve ( reduce ) with time. Lateral Tibial torsion usually worsens with growth.
Rotational Deformities Clinical Examination Rotational Profile At which level is the rotational deformity? How severe is the rotational deformity? Four components: 1- Foot propagation angle. 2- Assess femoral rotational arc. 3- Assess tibial rotational arc. 4- Foot assessment.
Rotational Deformities Clinical Examination Rotational Profile 1- Foot propagation angle – Walking Normal Range: +10 o _ 10 o ? In Eastern Societies +25 o _ 10 o
Rotational Deformities Clinical Examination Rotational Profile 3- Tibial Rotational Arc Thigh-foot angle in prone foot position is critical leave to fall into natural position
Rotational Deformities Clinical Examination Rotational Profile 4- Foot assessment Metatarsus adductus Searching big toe Everted foot Flat foot
Out-toeing : Normal seen when infant positioned upright ( usually hips laterally rotate in-utero ) Metatarsus adductus : medial deviation of forefoot 90 % resolve spontaneously casting if rigid or persists late in 1st year Rotational Deformities Common Presentations Infants
Rotational Deformities Common Presentations Toddlers In-toeing most common during second year. ( at beginning of walking ) Causes : – medial tibial torsion. –metatarsus adductus. –abducted great toe.
Rotational Deformities Common Presentations Toddlers - Medial Tibial Torsion The commonest cause of in-toeing Observational management is best Avoid special shoes / splints / braces – unnecessary, ineffective, interferes with activity and cause psychological and behavioral problems.
Rotational Deformities Common Presentations Serial casting is effective in this age-group Usually correctable by casting up to 4 years Toddler - Metatarsus Adductus
Rotational Deformities Common Presentations Dynamic deformity Over-pull of Abductor Hallucis Muscle during stance phase Toddlers - Abducted Great Toe Spontaneously resolve - no treatment
Rotational Deformities Common Presentations Child In-toeing : due to medial femoral torsion Out-toeing : in late childhood lateral femoral / tibial torsion
Rotational Deformities Common Presentations Child Medial Femoral Torsion Usually: - starts at years, - peaks at 4 – 6 years, - then resolves spontaneously. Girls > boys. Look at relatives - family history – normal. Treatment usually not recommended. If persists > 8 years and severe, may need surgery.
Rotational Deformities Common Presentation Stands with knees medially rotated (kissing patellae). Sits in W position. Runs awkwardly (egg-beater). Family History Medial Femoral Torsion (Ante-version)
Rotational Deformities Common Presentations Child Lateral Tibial Torsion Usually worsens. May be associated with knee pain (patellar) specially if LTT is associated with MFT. ( knee medially rotated and ankle laterally rotated )
Rotational Deformities Common Presentations Child Medial Tibial Torsion Less common than LTT in older child May need surgery if : –persists > 8 year, –and causes functional disability
Rotational Deformities Management Challenge : dealing effectively with family In-toeing : spontaneously corrects in vast majority of children as LL externally rotates with growth - Best Wait !
Rotational Deformities Management Convince family that only observation is appropriate < 1 % of femoral & tibial torsional deformities fail to resolve and may require surgery in late childhood.
Rotational Deformities Management Attempts to control child’s walking, sitting and sleeping positions is impossible and ineffective cause frustration and conflicts. She wedges and inserts : ineffective. Bracing with twisters :ineffective - and limits activity. Night splints : better tolerated - ? Benefit.
Rotational Deformities When To Refer ? Severe & persistent deformity. Age > 8-10y. Causing a functional dysability. Progressive.
Rotational Deformities Management When Is Surgery Indicated ? In older child ( > 8 – 10 years ). Significant functional disability. Not prophylactic !
Leg Aches / Growing Pains
Incidence : % of children. More In girls / At night / In LL. Diagnosis is made by exclusion.
Leg Aches / Growing Pains History Vague pain. Poorly localised. Bilateral. Nocturnal. Seldom alters activity. Long duration.
Leg Aches / Growing Pains Examination General health is normal. No deformities. No joint stiffness. No tenderness. Normal gait. No limping.
Leg Aches / Growing Pains Management When atypical history or signs present on examination: –Imaging and lab. Studies. If all negative : –Symptomatic treatment : Heat / Analgesics. –Reassure family : Benign. Self-limiting. Advise to re-evaluate if clinical features change.
Leg Aches / Growing Pains FeatureGrowing PainSerious Problem History : Long durationOftenUsually not Pain localisedNoOften Pain bilateralOftenUnusual Ulters activityNoOften Cause limpingNoSometimes General healthGoodMay be ill From Stahili : Practice of Pediatric Orthopedics 2001
Leg Aches / Growing Pains FeatureGrowing PainSerious Problem Physical examination : TendernessNoMay show GuardingNoMay show Reduced rang of motionNoMay show Laboratory : CBCNormal? Abnormal ESRNormal? Abnormal From Stahili : Practice of Pediatric Orthopedics 2001
CDH / DDH Congenital Dislocation of Hip. Developmental Dysplasia of Hip.
CDH Spectrum Teratologic Hip : Fixed dislocation Often with other anomalies Dislocated Hip : Completely out May or may not be reducible Subluxated Hip : Only partially in Unstable Hip : Femoral head can be dislocated Acetabular Dysplasia : Shallow Acetabulum Head Subluxated or in place
CDH Clinical Examination Look : Shortening ( not in neonates ) - Galeazzy sign - in supine
CDH Neonatal Examination MOVE : Hip instability in early infancy Limited hip abduction in flexion - later (careful in bilateral) if <60 0 on both sides: request imaging
CDH Neonatal Examination
CDH Neonatal Examination Hip Flexion Deformity SPECIAL : Loss of fixed flexion deformity of hips in early infancy. Normally FFD: –newborn 28 o –at 6 weeks 19 o –at 6 months 7 o Normal FFD CDH No FFD Thomas Test
CDH Neonatal Examination Ortolani TestBarlow Test
CDH Clinical Examination Hip clicks : - fine, short duration, high pitched sounds - common and benign – from soft tissues Hip clunks : - sensation of the hip displacing over the acetabular margin If in doubt : U/S in young infants single radiograph if > 2-3 months